At times, the ethical principle of confidentiality will conflict with other critical ethical principles. These conflicts might arise when a child and adolescent psychiatrist (CAP) obtains information concerning suspected child maltreatment (i.e., child abuse or neglect). This information that might be needed to end child maltreatment and protect children. Each state has a system in place to receive and respond to reports of suspected child maltreatment. CAPs are expected to know what standards apply in their state of practice and must report any form of suspected child maltreatment that falls within those standards.

Decision-making in child and adolescent psychiatry brings with it a variety of challenges for children, parents/guardians, and child and adolescent psychiatrists. It relies on the concepts of assent and consent by proxy, which is the focus of Principle IV of the AACAP Code of Ethics (2014). Assent recognizes that minors might not, due to their developmental level, be capable of giving completely reasoned consent; however, minors might be capable of having preferences and communicating their preference. Assent recognizes the importance of the involvement of minors in the decision-making process, while also recognizing that a minor's level of participation is less than completely competent. Minors ought to participate in decision-making proportionate to their developmental level. Minors ought to provide assent to care whenever reasonable. Parents/guardians and child and adolescent psychiatrists should not exclude minors from decision-making without clear and convincing reasons.

American Academy of Child and Adolescent Psychiatry. Practice parameter on the use of psychotropic medication in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2009 Sep;48(9):961-73. doi: 10.1097/CHI.0b013e3181ae0a08. PubMed PMID: 19692857.

Belitz J, Bailey RA. Clinical ethics for the treatment of children and adolescents: a guide for general psychiatrists. Psychiatr Clin North Am. 2009 Jun;32(2):243-57. doi: 10.1016/j.psc.2009.02.001. Review. PubMed PMID: 19486811.

While many child and adolescent psychiatrists (CAPs) assume that physician-patient boundaries are well defined by ethical and legal standards, boundary issues (e.g., boundary crossings or boundary violations) are a multifaceted and controversial aspect of clinical practice. CAPs establish boundaries with each patient for the purpose of promoting a trusting, therapeutic-fiduciary alliance. Boundary crossings are about deviating from traditional therapeutic activity and are not about exploitation. Boundary violations are harmful to patients and are about exploitation.

Principle V of the AACAP Code of Ethics (2014), the ethical principle of confidentiality, focuses on a patient's and a patient's guardian's/parent's right to have their information kept private and confidential. Child and adolescent psychiatrists (CAPs) should inform patients and their parents/guardians about confidentiality and any known limitations to confidentiality at the start of each therapeutic relationship. They need to be informed that threats of harm to self or others will not be kept confidential.

Confidentiality is a frequent concern in child and adolescent psychiatry, because parents/guardians commonly initiate care for their youth. The parents/guardians legitimately expect feedback from the CAPs to attempt improved care for their children.

Pediatric psychosomatic medicine often addresses ethical issues related to capacity, consent, confidentiality, autonomy, emancipation and dual agency. There is also an increasing necessity for ethical awareness in pediatric psychosomatic medicine to factors such as:

The advancements in medicine have led to more complex medical treatment options requiring the patient and the patient's parent(s)/guardian(s) to have a higher level of decision-making capacity;

The advancements in life-saving medical technology have led to a decline in childhood mortality rates (in conditions such as HIV and cancers), which has resulted in an increasing number of children are surviving into adulthood with chronic medical conditions;

A growing number of patients and their families are pursuing social media and other online sources to obtain their medical information (which is not necessarily accurate), connect with others affected by similar medical conditions, and play a more active role in their healthcare decisions;

Charting in electronic health records makes child and adolescent psychiatrist's charting more accessible to a variety of medical providers; and,

Diverse religious, spiritual and ethnic characteristics of the patient population, which brings with it a focus on providing culturally competent care.

Electroconvulsive Therapy (ECT) is recognized therapy for adults with treatment resistant psychiatric disorders, most commonly depressive and psychotic disorders as well as life threatening conditions such as catatonia. Research and clinical practice has demonstrated that ECT is effective and safe. There is little data on its use in youth, particularly children due to historical concern about this treatment approach. Clinically, ECT mostly has been utilized in the treatment of psychiatrically ill adolescents, for the same conditions that adults are treated with ECT for. There is a significant need for additional research to document the effectiveness and safety of ECT for the care of children and adolescents. Major ethical issues include assent/ consent, concern about best interests and doing no harm, and advocacy.

Foster care is sponsored and managed by state child protective services for youth who are unable to be cared for by their families. The system is designed to provide support and safety for children and adolescents who have been neglected and abused. In addition to ensuring safety, the priority is to support and help the family so that the involved children and adolescents can be returned to their families. Youth are usually placed with designated families, with some use of group home; it is designed to be a temporary placement. There are multiple ethical issues related to the care of these children which include: developmentally inadequate/ problematic placements and environments; challenges in determining the parameters of best interests and doing no harm; difficulties obtaining truly informed assent/consent for interventions; complicated situations related to confidentiality; significant third party influences; challenges doing scholarship with vulnerable populations; need for significant advocacy and justice activities; difficulties in finding child psychiatrists to provide care for many reasons, including often inadequate professional rewards; and major, pervasive legal considerations.

COUNCIL ON FOSTER CARE; ADOPTION, AND KINSHIP CARE; COMMITTEE ON ADOLESCENCE, and COUNCIL ON EARLY CHILDHOOD. Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics. 2015 Oct;136(4):e1131-40. doi: 10.1542/peds.2015-2655. PubMed PMID: 26416941.

There is increasing recognition that much needs to be discovered and explored in terms of how individuals acquire and maintain their sense of gender identity with the recognition that this aspect of sexuality and identify is more fluid and diverse than the categories of male and female. Along with increasing evidence that gender identity is biologically determined, it is becoming more evident that discrepancies between biological sex and identified gender are more common than previously thought. With the advances in medicine and ever broadening options for intervention, significant ethical issues relevant to development, best interests, no harm and assent/consent exist when determining how to best care and support these youth who have gender issues.

When treating children and adolescents, involuntary commitment for psychiatric care is complicated by having to consider the opinions of the parents and the youth. While youth can be hospitalized voluntarily if their parents agree, having the child or adolescent disagree with the plan does complicate the situation. Assent/consent are major issues as well as best interests/no harm and development. Given that some populations are more likely to be involuntarily committed, advocacy and justice should always be considerations.

Managed care organizations (MCOs) are expected to ensure appropriate uses of clinical resources, provide coverage for a range of services covered by the particular plan, maintain level of care guidelines derived from medical necessity guidelines, have processes in place for appeals, grievances, complaints, and independent external reviews, and provide quality management oversight. MCOs may seek accreditation from NCQA (National Council of Quality Assurance) or from URAC (Utilization Review Accreditation Commission) although accreditation is not required of MCOs. MCOs may include behavioral health services or in carve out states. There are separate managed care companies for behavioral health called MBHOs or BHMCOs. Ethical issues are inevitable. Ethical considerations may involve multiple stakeholders with competing agendas relative to psychiatric evaluation and treatment, confidentiality concerns, HIPPA, the not so bright line between what is classified as treatment and what may reflect the psychosocial adversity safety net, and consequences when other systems do not step up. AACAP Code of Ethics Principle VI, third party Influence, specifically addresses that CAPs are expected not to allow third parties (includes insurance companies), potential or actual compensation to influence professional judgment and action. However there are additional ethical issues for the CAP: advocacy and equity (justice) so that a full range of quality services are available for children, youth and families, professionalism, i.e., being prepared for peer reviews, clear about the diagnoses, treatment plans, risks and benefits of treatment, understanding the level of care guidelines, knowledgeable about how CAPs and parents/guardians can advocate for denied services using the grievance and appeal process.

Psychopharmacology has become an essential aspect of psychiatric care for children and adolescents. Medications can be a crucial, beneficial adjunct to a comprehensive, multidimensional treatment plan. For some youth and conditions, use of several medications simultaneously is required. Unfortunately, in many systems, there is a lack of accessible psychotherapeutic and psychosocial interventions so medications can be overly relied upon and youth end up on multiple medications unnecessarily. Best interests and doing no harm are major considerations when prescribing; so is informed assent/consent.

Di Pietro Nina, Illes Judy (eds) The Science and Ethics of Antipsychotic Use in Children. San Diego: Academic Press, 2015.

Psychotherapy

Many ethical issues can present when treating children and adolescents with psychotherapy. These issues include but are not limited to consent, assent, release of information, disclosure of information to parents, guardians and other stakeholders, multiple relationships, boundary crossings and violations, therapy in the context of custody issues, gifts, social media in the context of psychotherapy. One of the key differences between adult and child and adolescent therapy are the ethical dilemmas that arise when treating dependent minors. These concerns are elaborated in the AACAP Code of Ethics (2014) within the preamble and Principle I (the developmental perspective).

Chemical restraint is defined within 42CFR 483.352 as "drug used as restraint means any drug that: is administered to manage a resident's behavior in way that reduces the safety risk to the resident or others; has the temporary effect of restricting the resident's freedom of movement; and is not a standard treatment for the resident's medical or psychiatric condition." The term pharmacologic restraint has been used as well as chemical restraint. The use of chemical restraint is related to the use of PRN medications and STAT medications. Some states prohibit the use of standing orders for PRNs for psychotropic medications in certain levels of care. For example, in Pennsylvania it is permissible to use PRNs for acute behavioral control in psychiatric inpatient settings for children and adolescents, but such use of PRNs is prohibited in psychiatric residential treatment centers, though STAT medication is permitted. STAT medication requires a physician's order, clinical rationale and a face-to-face assessment prior to the psychotropic being administered. These distinctions between chemical restraint, standing PRN orders and STAT medication and the regulations may vary from state to state but do provide a stimulus for ethical issues of balancing safety, risk to self and/or others with a child's autonomy, the use of the least restrictive means to ensure safety and the potential for abuse of psychotropic medications for sedation and convenience. Psychoeducation and relationship building with the youth and family needs to cover scenarios in advance as to when a medication may be used to address escalating aggression or self harm. When CAP has responsibilities for the oversight of the treatment milieu, there are ethical duties to ensure both quality of care and safety in the treatment settings.

Physical restraint and seclusion are considered as last resort interventions when less restrictive means have not been effective at reducing serious safety threats directed at either the child or adolescent themselves or directed at others. The Centers for Medicaid & Medicare Services (CMS) defines seclusion as the involuntary confinement of a patient in a room or area from which the patient is physically prevented from leaving. Restraint is defined as any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move. The use of medication to restrain the patient's movements is included within the types of restraint. There are federal regulations by CMS specifying the type of professional can order restraint and seclusion, the timeframe for such orders to be written, for in-person evaluation must occur, renewals for orders, and for re-evaluation. There are different requirements for children under 9 years of age and for those 9 to 17 years of age. States may impose stricter criteria and some states forbid the use of prone restraints. Since the early 2000's there has been concerted efforts to reduce the use of restraint and seclusion, provide alternative interventions and to recognize the role of trauma relative to restrictive procedures. The ethical issues surrounding the use of restrictive procedures include the use of restraint/seclusion as punishment, or for convenience, as a consequence of power differential , and neglect of the duty to ensure beneficence, non-malfeasance. The article by Masters et al. (2013) discusses the ethical issues when a CAP participants in restraint.

The intersection of social media and ethics covers a wide range of topics and continues to evolve as there are more opportunities for interactions among psychiatrists, patients and their families in both professional and non-professional domains. While the internet, texting, email communications offer certain advantages, the use of social media comes with the need to review basic ethical principles and how they are applied to digital communication. These principles include confidentiality and privacy, boundaries, conflict of interest disclosure. In addition, legal issues such as liability, intellectual property, mandated reporting are impacted.